A polling firm asked Americans across the country, “What do you need to be healthy?” Across political party, race, age, region, and socioeconomic status, respondents acknowledged that health care only partly contributes to health. What makes a significantly larger impact on health – they agreed – were factors like affordable housing, safe neighborhoods, healthy foods, and employment. In formal settings, these factors have been identified as the social determinants of health (SDOH).1
Primarily outside of the clinical realm, SDOH includes2:
- Social factors (employment, family and social support, income, education)
- Behaviors (diet and exercise, tobacco, alcohol and drugs, sexual activity)
- Environmental factors (housing, air and water quality, transportation)
A significant body of evidence has shown that up to 80% of a person’s health is determined by SDOH.2 As Tom Freidan, former director of the Centers for Disease Control and Prevention, explains, “Your health is more affected by your zip code than by your genetic code.”
While Americans may agree on what they need to be healthy, there is limited consensus on how these factors should be addressed. We often hear that the U.S. spends 17% of GDP on health care – far more than other OECD nations. Less commonly discussed, however, is that America spends substantially less on social services: for every dollar spent on health care, the U.S. spends another $1.00 on social services, a sharp contrast to the $2.50 invested by other OECD countries. With health care in America not currently set up to look at the distal causes of disease and social services underfunded, it is not surprising that many health outcomes in the U.S. lag behind our OECD partners.3
As health care transitions from fee-for-service to value-based care, adopting upstream approaches that address SDOH is coming to the forefront as an effective – and necessary — way to lower healthcare costs and improve care quality, particularly among underserved communities with poor health outcomes. Realizing that success under alternative payment models depends on keeping patients healthy and out of the physician’s office, providers and payers are beginning to capitalize on the shortage of social services by incorporating SDOH into their benefits programs and initiatives.
“If we want to see better health results and lower costs down the road, then addressing social factors has to be part of the package,” said Elaine Waxman, a senior fellow at the Urban Institute.4
For example, recent initiatives addressing food insecurity and homelessness have proven very effective:
- When the University of Illinois Hospital found that just 200 of its chronically homeless patients were in the 10th decile for patient cost, they partnered with a community group called the Center for Housing and Health. As part of this initiative, patients experiencing chronic homelessness were paired with an outreach worker who facilitated transitional housing and developed long-term solutions for independent living. Almost immediately, participant healthcare costs fell 42%, and more recent studies have found that costs dropped by 61%.5
- In 2014, Advocate Health Care, a Chicago-based ACO, launched a quality-improvement initiative targeting malnutrition in their hospitals. All patients were screened at admission for malnutrition risk, and high-risk patients received nutrition education, post-discharge instructions, follow-up calls, and coupons for retail oral national supplements. Within 6 months, Advocate reduced healthcare costs by $3,800 per patient (a $4.8 million total savings), and recorded a 30-day readmission rate reduction of 27%.5
- In 2016, Geisinger created the Fresh Food “Farmacy”, in which uncontrolled type 2 diabetics with food insecurity received a “prescription” for healthy, diabetes-appropriate food for both themselves and their families. These patients were also paired with a multidisciplinary team of both healthcare providers and nonclinical support personnel. Within 12 months, Geisinger saw enrollees’ HbA1c levels drop by more than 2 points, corresponding to a more than 40% decrease in risk of death or serious complications — a more drastic change than even a second or third diabetes medication can offer.6, 7
Health care and public expenditure on social services continue to be controversial topics in the U.S., but finding adequate ways to address SDOH factors will ultimately benefit both healthcare delivery systems and patients.
Onie, Rebecca. What If Our Health Care System Kept Us Healthy? [videotape]. TED: Ideas Worth Spreading; 2012. Accessed at www.ted.com/talks/rebecca_onie_what_if_our_healthcare_system_kept_us_healthy.
Bailey, David J. Value-based care alone won’t reduce health spending and improve patient outcomes. Harvard Business Review Website. hbr.org/2017/06/value-based-care-alone-wont-reduce-health-spending-and-improve-patient-outcomes. Published June 16, 2017. Accessed December 24, 2018.
OECD (2017), Health at a Glance 2017: OECD Indicators, OECD Publishing, Paris. https://doi.org/10.1787/health_glance-2017-en.
Johnson, SR. HHS test will try addressing social needs to improve health. Modern Healthcare Website. www.modernhealthcare.com/article/20160105/NEWS/160109959. Published January 5, 2016. Accessed October 24, 2018.
LePointe J. How addressing social determinants of health cuts healthcare costs.” RevCycle Intelligence Website. https://revcycleintelligence.com/news/how-addressing-social-determinants-of-health-cuts-healthcare-costs. Published June 25, 2018. Accessed October 24, 2018.
Feinberg A, Slotkin JR, Hess A, Erskine AR. How geisinger treats diabetes by giving away free, healthy food. Harvard Business Review Website. https://hbr.org/2017/10/how-geisinger-treats-diabetes-by-giving-away-free-healthy-food. Updated October 25, 2017. Accessed October 24, 2018.
Feinberg AT, Hess A, Passaretti M, Coolbaugh S, Lee TH. Prescribing food as a specialty drug. NEJM Catalyst Website. https://catalyst.nejm.org/prescribing-fresh-food-farmacy/. Published April 10, 2018. Accessed October 24, 2018.